JOA - 2026-06-18 - Journal Article
Impact of Intervention Timing on the Failure of Debridement, Antibiotics, and Implant Retention for Acute Postoperative Periprosthetic Joint Infections: A Contemporary United States Population-Level Analysis.
Zedan AM, Barber T, Bini SA, Diaz-Ledezma C
Topics
Key Takeaway
DAIR failure rates rise from 37.7% at ≤4 weeks to 55.2% at 10–12 weeks, with joinpoint regression identifying a critical inflection point at approximately 7 weeks post-arthroplasty beyond which failure risk accelerates disproportionately.
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Summary
This study asked whether DAIR timing within 12 weeks of primary THA or TKA affects treatment failure, using a national US claims database (2010–2023) with patients stratified into 2-week intervals. Failure was defined as any subsequent septic surgical intervention within 2 years. Failure rates were statistically similar at ≤4 weeks (37.7%) and 4–6 weeks (40.1%, aOR 1.08), but rose significantly from 6–8 weeks onward, peaking at 55.2% and aOR 2.12 at 10–12 weeks, with the inflection point at ~7 weeks driven primarily by TKA outcomes.
Key Limitation
Claims-based data preclude adjustment for pathogen identity and virulence, which are among the strongest predictors of DAIR failure and could systematically bias timing-outcome associations if more virulent organisms present earlier.
Original Abstract
BACKGROUND
Time to intervention is a critical determinant of failure after debridement, antibiotics, and implant retention (DAIR) in acute postoperative periprosthetic joint infection (PJI). While International Consensus Meeting (ICM) guidelines have expanded the recommended therapeutic window for DAIR from four to six weeks, emerging European data suggest extension to 12 weeks. This study evaluated the association between DAIR timing and treatment failure after primary total hip (THA) and knee (TKA) arthroplasty, leveraging a large United States database to identify an optimal timing threshold.
METHODS
This was a retrospective cohort study using a national claims database (2010 to 2023) of adults who had an acute postoperative PJI undergoing DAIR within 12 weeks of primary THA or TKA. Patients were stratified into two-week intervals (≤ four weeks as reference). Treatment failure was defined as any septic surgical intervention within two years. Multivariable logistic regressions adjusted for demographic and clinical factors. Segmented (joinpoint) regressions identified an inflection point of risk as a threshold for DAIR timing.
RESULTS
Among 7,795 DAIR procedures, failure rates were similar at ≤ four weeks (37.7%) and four to six weeks (40.1%; P = 0.06), but increased significantly thereafter: six to eight weeks (45.2%), eight to 10 weeks (50.4%), and 10 to 12 weeks (55.2%) (all P < 0.001). Adjusted odds of failure were stable at four to six weeks (aOR 1.08; 95% confidence interval (CI) 0.94 to 1.25), but rose progressively, peaking at 10 to 12 weeks (aOR 2.12; 95% CI 1.73 to 2.58). Joinpoint regression identified an inflection point at approximately seven weeks post-arthroplasty, beyond which risk accelerated significantly. Joint-specific analyses demonstrated that this effect was driven by TKA, which showed progressively higher failure with increasing time to DAIR.
CONCLUSION
Our findings show DAIR efficacy for acute postoperative PJI is time-dependent. While outcomes remain stable through approximately seven weeks after index arthroplasty, interventions beyond this threshold are associated with a disproportionate increase in failure risk. Our findings are in general agreement with the recommendations of the 2025 ICM.